HIP JOINT DISLOCATION

By: dr. Syafruddin, Sp. B

Editor: Nurhayati, S.Ked

Introduction
Epidemiology
rare, but high incidence of associated injuries mechanism is usually young patients with high energy trauma

Hip joint inherently stable due to

bony anatomy soft tissue constraints including
labrum Capsule ligamentum teres

Classification
Simple vs. Complex
simple
pure dislocation without associated fracture

complex
dislocation associated with fracture of acetabulum or proximal femur

 Anatomic classification 1. posterior dislocation (90%)

occur with axial load on femur, typically with hip flexed and adducted axial load through flexed knee (dashboard injury)

 position of hip determines associated acetabular injury

increasing flexion and adduction favors simple dislocation

associated with
osteonecrosis posterior wall acetabular fracture femoral head fractures sciatic nerve injuries ipsilateral knee injuries (up to 25%)

2. anterior dislocation
associated with femoral head impaction or chondral injury occurs with the hip in abduction and external rotation inferior vs. superior
hip extension results in a superior (pubic) dislocation flexion results in inferior (obturator) dislocation

Presentation
Symptoms
acute pain, inability to bear weight, deformity

Physical exam
ATLS
95% of dislocations with associated injuries

 posterior dislocation (90%)

hip and leg in slight flexion, adduction, and internal rotation
detailed neurovascular exam (10-20% sciatic nerve injury) examine knee for associated injury or instability

internal rotation

 anterior dislocation
hip and leg in flexion, abduction, and external rotation

external rotation

Imaging
Radiographs
can typically see posterior dislocation on AP pelvis
femoral head smaller then contralateral side Shenton's line broken lesser trochanter shadow reveals internally rotated limb as compared to contralateral side scrutinize femoral neck to rule out fracture prior to attempting closed reduction

 CT
a. helps to determine direction of dislocation, loose bodies, and associated fractures
anterior dislocation

 posterior dislocation

b. post reduction CT must be performed for all traumatic hip dislocations to look for femoral head fractures

 loose bodies

acetabular fractures

 MRI
controversial and routine use is not currently supported useful to evaluate labrum, cartilage and femoral head vascularity

Treatment
1. Nonoperative
emergent closed reduction within 6 hours
indications
acute anterior and posterior dislocations

contraindications
ipsilateral displaced or non-displaced femoral neck fracture

2. Operative
open reduction and/or removal of incarcerated fragments
indications
irreducible dislocation radiographic evidence of incarcerated fragment delayed presentation non-concentric reduction should be performed on urgent basis

3. ORIF

indications
associated fractures of acetabulum femoral head femoral neck should be stabilized prior to reduction

4. arthroscopy indications
no current established indications potential for removal of intra-articular fragments evaluate intra-articular injuries to cartilage, capsule, and labrum

Techniques
Closed reduction
perform with patient supine and apply traction in line with deformity regardless of direction of dislocation must have adequate sedation and muscular relaxation to perform reduction assess hip stability after reduction post reduction CT scan required to rule out
femoral head fractures intra-articular loose bodies/incarcerated fragments
may be present even with concentric reduction on plain films acetabular fractures

post-reduction
for simple dislocation, follow with protected weight bearing for 4-6 weeks

 Open reduction
approach
posterior dislocation
posterior (Kocher-Langenbeck) approach

anterior dislocation
anterior (Smith-Petersen) approach

technique
may place patient in traction to reduce forces on cartilage due to incarcerated fragment or in setting of unstable dislocation repair of labral or other injuries should be done at the same time

Complications
Post-traumatic arthritis
up to 20% for simple dislocation, markedly increased for complex dislocation

Femoral head osteonecrosis

5-40% incidence Increased risk with increased time to reduction

Sciatic nerve injury

8-20% incidence associated with longer time to reduction

Recurrent dislocations
less than 2%

Jazakallah..... ^_^